"I was angry at people who were happy"
Five months after being diagnosed with femoroacetabular impingement, I had surgery to remove bone from my femur that was impinging against my acetabulum. I was still in my third year of medical school. I used opioids and sedative hypnotics for a month after surgery and then stopped. At this point, stopping was easy; I did not even think about it. I thought that because I'd had the surgery, the source of my pain was gone and eventually I would feel like myself again.

But 3 months later, the pain slowly returned. My thought—and it's difficult to shake even now—was that I'd waited too long to have the surgery. Both my surgeon and I believed that the only remaining option was a hip replacement. But I wasn't ready for another surgery. I was about to start residency and just didn't have time.

When the sharp stabbing pain occurred, it ruined my day and left me feeling like an old man. My gait was changing, and I walked with a limp. I felt trapped in my old feeble body and thought I could do nothing to change.

During my intern year, I experienced sporadic neck pain with some numbness running down my right arm. After about 3 months, the pain worsened. An MRI showed that I had a herniated disk. With some reluctance (dreading another surgery), I decided to see a neurosurgeon.

The neurosurgeon diagnosed a severe disk herniation at C6-C7. I remember thinking, "Are you kidding me? Do I really have to have another surgery, this time in residency?" I wanted to try nonsurgical treatment even though I was told that the severity of the herniation would mean an eventual surgery. I was prescribed hydrocodone/acetaminophen, cyclobenzaprine, Neurontin, and a Medrol dose pack. I used everything but the cyclobenzaprine. I didn't like the sedation it caused during the day.

At some point, I began taking Ambien again because I was having trouble sleeping. I was told to avoid weight training and most other exercise to help prevent further progression of my symptoms. This was very difficult for me because I had been an active, fit athlete. Now, I could no longer be myself.

When weakness developed, I had the surgery, which immediately reduced my neck pain and radiculopathy. Within 3 months, I was symptom-free. It was like magic. I remember feeling upset that my hip surgery had not been as successful.

But I had lost that youthful feeling of invincibility. Both of my surgeons told me to limit exercise and sports, but neither really understood the impact of their recommendations. With the best of intentions, they were telling me that being myself was not an option.

Before I entered medical school, I had completed a master of science degree in exercise physiology. Now I could not practice what I had preached for years. This was not simply changing activities; I had to change my lifestyle, and I did not handle this well to say the least. I once saw myself as a healthy, strong athlete who had been in peak physical condition as a body builder. Now I felt weak, sick, and vulnerable. I was struggling to survive.

I was also getting depressed. I was in a constant state of unease. Initially I remember taking an occasional extra Ambien or oxycodone left over from the surgery. but now I was taking them to relieve stress.

At this point, my unethical behavior started. Instead of seeing my doctor every few months to re-evaluate my use of or need for medication, I would just call for a refill. If the doctor asked me to come in to be evaluated, that was no problem. I would always get the prescriptions.

It was very easy to get as much medication as I wanted. I became manipulative and no one was checking on me. My doctors did not suspect my increasing depression or my use of ineffective coping strategies because I never brought it up and would mask my depression during office visits. That "elephant in the room" was never considered.

My depression turned to anger. I was angry at people who were happy, people who didn't have a drug problem, people who didn't have pain issues, people who weren't experiencing withdrawal. I was desperate for even a few hours of happiness, which the drugs provided.

Whatever happened at work, I had a surefire way to feel good when I got home. It may sound crazy, but I was convinced that I could practice feeling good by using drugs and then gradually learn to get there without drugs.

Sometimes I minimized my use, but I never stopped. All kinds of stresses—an argument with my girlfriend, a disagreement at work—drove me back to the drugs. Over time I needed stronger doses to get the feeling of ease.

When my doctors found out that I was getting drugs from multiple physicians, they stopped all prescriptions. But I always found a way to get the drugs I wanted. I got them on the street, from friends, or by other means. To put it simply, it was much easier and faster to get drugs than it was to get help. In my depression, I had no time or energy to work on an alternative, less self-destructive way to feel good. I thought to myself, "I'm a doctor. I don't have time to find another way, I have patients to take care of." Looking back, I can see how comical my arrogance was.

I tried to stop many times on my own and simply could not do it. I experienced a feeling of helplessness that is hard to describe. I remember telling myself that people would think that I should not be allowed to be a doctor because I could not even take care of myself.
Finally, I accepted the fact that I needed help. But I realized that to get help, I would need to tell my residency director, and put my career at risk. That scared me more than death.

Next month in AAOS Now, Dr. Attum shares how he tried to quit on his own, and how his inability to do so ultimately led to the loss of his residency slot.

Basem Attum, MD, MS, is currently a research coordinator at the Division of Orthopaedic Trauma, Vanderbilt University Medical Center. He can be reached at baattum@gmail.com.

From the Patient Safety Committee
As a medical student and resident, Basem Attum, MD, MS, struggled with addiction. Part 1 of his story, "My Substance Use Disorder: Recovery and Redemption," appeared last month in AAOS Now. In this article, he shares how his dependence on medications increased; future articles will discuss how addicts delude themselves and others about their drug use and how Dr. Attum eventually beat his addiction.

As physicians and surgeons, we may focus on medicine and surgery as "cures," to the detriment of other coping strategies. We may also transfer those beliefs to our patients, perhaps unwittingly contributing to the growing epidemic of substance misuse.

"I trust this story is as moving for readers as it was for those of us who heard it in person," said David Ring, MD, PhD, chair of the AAOS Patient Safety Committee. "I admire Dr. Attum's courage in sharing his story. I am certain that he will help prevent many addictions and help others get out of established patterns of misuse."

The AAOS Patient Safety Committee has a number of online resources to help physicians and surgeons provide safe pain relief strategies to patients. For more information, visit www.aaos.org/Quality/PainReliefToolkit.